Interdisciplinary communication in the intensive care unit

Tom W. Reader, R. Flin, Kathryn Mearns and Brian H. Cuthbertson

Interdisciplinary communication in the intensive care unit Article (Accepted version) (Refereed) Original citation: Reader, Tom W. and Flin, R. and Mearns, Kathryn and Cuthbertson, Brian H. (2007) Interdisciplinary communication in the intensive care unit. British journal of anaesthesia, 98 (3). pp. 347-352. DOI: 10.1093/bja/ael372 © 2007 Oxford University Press This version available at: http://eprints.lse.ac.uk/29088/ Available in LSE Research Online: March 2011 LSE has developed LSE Research Online so that users may access research output of the School. Copyright © and Moral Rights for the papers on this site are retained by the individual authors and/or other copyright owners. Users may download and/or print one copy of any article(s) in LSE Research Online to facilitate their private study or for non-commercial research. You may not engage in further distribution of the material or use it for any profit-making activities or any commercial gain. You may freely distribute the URL (http://eprints.lse.ac.uk) of the LSE Research Online website. This document is the author’s final manuscript accepted version of the journal article, incorporating any revisions agreed during the peer review process. Some differences between this version and the published version may remain. You are advised to consult the publisher’s version if you wish to cite from it.

Published as: Reader, T., Flin, R., Mearns, K., & Cuthbertson, B. (2007). Interdisciplinary communication in the Intensive Care Unit. British Journal of Anaesthesia, 98, 347-352

Interdisciplinary communication in the Intensive Care Unit Tom W Reader MA*, Rhona Flin PhD*, Kathryn Mearns PhD*, Brian H Cuthbertson** MD FRCA, *School of Psychology, University of Aberdeen, Kings College, Aberdeen, Scotland, UK, AB24 2UB **Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZD. Short title: Interdisciplinary communication in the ICU Name of institution where worked performed- University of Aberdeen, Aberdeen Scotland, UK. Address for correspondence: Mr Tom Reader, School of Psychology, University of Aberdeen, Kings College, Aberdeen, Scotland, UK, AB24 2UB Phone +44 1224 273212; Fax +44 1224 273211; E-mail [email protected] Financial support: This work was supported by a PhD studentship from the College of Life Sciences and Medicines, University of Aberdeen. Reprints: Will not be offered. Conflicts of interest: None. Financial interests: None of the authors have any financial interests relating to this work.

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SUMMARY Background: Patient safety research has shown poor communication amongst ICU nurses and doctors to be a common causal factor underlying critical incidents in intensive care. The current study examines whether ICU doctors and nurses have a shared perception of interdisciplinary communication in the UK intensive care unit. Methods: Cross-sectional survey of ICU nurses and doctors in four UK hospitals using a previously established measure of ICU interdisciplinary collaboration. Results: A sample of 48 doctors and 136 nurses (47% response rate) from 4 ICUs responded to the survey. Nurses and doctors were found to have differing perceptions of interdisciplinary communication, with nurses reporting lower levels of communication openness between nurses and doctors. Compared to senior doctors, trainee doctors also reported lower levels of communication openness between doctors. Furthermore, a regression path analysis revealed that communication openness amongst ICU team members predicted the degree to which individuals reported understanding their patient care goals (adjR2 = 0.17). It also showed that perceptions of the quality of unit leadership predicted open communication. Conclusions: Members of ICU teams have divergent perceptions of their communication with one another. Communication openness amongst team members is also associated with the degree to which they understand patient care goals. In order to ensure team members in the ICU feel that they can communicate openly, it is necessary to create a safe atmosphere where team members feel they can communicate openly without fear of reprisal or embarrassment. Key words: Teamwork; Interdisciplinary communication; patient safety; leadership; patient care planning

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Introduction Effective team communication and coordination are recognised as being crucial for improving quality and safety in acute medical settings such as the intensive care unit (ICU)

1,2

. Research studying communication failures in medical teams has indicated

the influence that hierarchical and social factors have upon the behaviours of junior medical staff. Communication failures can emerge from junior team members being reluctant to communicate openly with senior team members because of a fear of either appearing incompetent, or of being rejected, embarrassed or reprimanded

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.

Attitudinal research in the US has indicated that ICU team members have divergent perceptions of their communication behaviours, with more nurses than doctors reporting difficulties in speaking-up about problems with patient care, and fewer nurses reporting that teamwork between nurses and doctors is well coordinated

4,5

.

Not only do such factors increase the likelihood of medical errors occurring 6, the degree to which communication in the ICU is open may also influence the degree to which patient care duties are understood. Through the use of communication interventions that promote teamwork across role boundaries (e.g. ICU daily goals sheets), making communication more inclusive and explicit has been shown to increase team members’ understanding of patient care plans in the ICU 7,8.

The current study examined whether nurses and doctors working in UK ICUs have differing perceptions of their interdisciplinary communication, with the prediction being that trainee team members (e.g. trainee doctors) will have less positive perceptions than senior team members (e.g. senior doctors). Furthermore, this study examined whether individuals who report higher levels of open communication within the ICU also report having a better understanding of their patient care goals, and

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whether the leadership of senior ICU staff is important in fostering a perception of communication openness.

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Method Participants The study was a cross-sectional survey carried out in 4 Scottish ICUs during July to December 2005. The ICUs were closed units (where patients are admitted only after approval, and are cared for full-time, by intensivists and their teams). Doctors and nurses agreed to be surveyed with regards to interdisciplinary collaboration in their unit (table 1). Ethical approval was acquired from relevant review bodies. At each location, a senior nurse distributed questionnaires to the nursing staff, and a senior doctor distributed questionnaires to the medical staff. In total, 400 questionnaires were distributed over the course of a month. The questionnaires were anonymous, with participants returning the completed questionnaires in freepost envelopes to the research team.

INSERT TABLE 1 HERE

Materials The survey measure was adapted from the ‘Interdisciplinary Collaboration’ questionnaire developed by Shortell et al. 9, which contains a range of questions on ICU communication between interdisciplinary groups (i.e. between nurses and doctors), and within interdisciplinary groups (i.e. between doctors). The tool is psychometrically well validated teamwork in the US

11-13

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, and has been used previously to assess ICU

. Twelve scales regarding communication and leadership

were taken from the survey instrument (table 2), and terminology was adapted for the UK with the help of an ICU consultant and an ICU senior nurse. One additional 5item scale was specially developed for the survey. This scale measured how often

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ICU staff feel they understand the patient care plans and potential safety risks for the patients under their care. The scale was based on questions used in studies examining the understanding of patient care duties

7,8

, was developed with ICU staff, and was

piloted successfully in the first surveyed unit. Biodata such as age and gender were not requested in order to ensure anonymity and increase participation in the study.

INSERT TABLE 2 HERE

Statistical analysis Prior to any analysis, the internal reliability of the questionnaire scales was assessed by calculating Cronbach’s alpha scores, (these indicate the consistency of responses to the items that comprise a questionnaire scale). A Cronbach’s alpha score of above 0.7 indicates acceptable consistency 14. All but three scales showed acceptable reliability (α >= 0.7). Two scales (accuracy between shifts, and accuracy within shifts) showed reliability slightly below the acceptance criteria (α > 0.6). Although not ideal, it was consistent with the original questionnaire validation criteria, and thus the scales were retained. However, the ‘shift communication between groups’ scale had unacceptably low reliability (α = 0.47) and was excluded from further analysis. The distribution of respondent scores was found to be normal for all scales except ‘Understanding patient care goals’, which had a negatively skewed distribution. In order to normalise the scale, a ‘log transformation’ was performed. Multivariate analysis of variance (MANOVA) was conducted to examine whether there was an overall effect for differences in responses to perceptions of communication between i) doctors and nurses, and between ii) senior doctors and trainee doctors, and senior nurses and trainee nurses. Post-hoc tests were then conducted to examine the specific differences

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between responses to the questionnaire scales, with Hochberg’s GT2 test procedure being used to test for comparisons where there was a large difference in the sample size. Additionally, the proportions of staff within each group that reported very positive perceptions (between 4 & 5) on each scale, (and thus may perceive a reduced need for improvements in teamwork) were calculated along with Cohen’s d effect sizes 15, which are used to examine the strength of an observed effect and are reported as Pearson’s correlation coefficients.

A multiple regression was conducted to examine whether open communication in the ICU predicts respondent reports of understanding patient care goals. Lastly, a mediation analysis using regression path analysis (which is used to examine the mechanisms through which one variable affects another, whilst taking into the account the variance explained by a third variable)

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examined whether unit

leadership was also important in predicting understanding patient care goals whilst taking into account the variance explained by reports of open communication in the ICU. Data were analysed using SPSS for Windows version 14.

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Results A total of 184 questionnaires were returned (47% response rate): 48 questionnaires (26% of the sample) were received from doctors (17 senior doctors, 13 specialist registrars, 15 senior house officers, and 3 unknown) and 136 (74% of the sample) were received from nurses (24 senior nurses and 112 staff nurses). The mean response scores showed a similar pattern of results to the original US scale 9, with the majority of respondents reporting positive responses to the questionnaire scales (table 2). The MANOVA showed a significant effect (λ= .750, F(14, 164) = 3.59, p